MedCosmos Surgery
Surgery Lecture Notes, Books, MCQ and Good Articles
Friday, September 5, 2008
Enocrine Surgery MCQ
1. When progressive enlargement of a multinodular goiter causes
symptomatic tracheal compression, the preferred management in
otherwise good-risk patients is:
A. Iodine treatment.
B. Thyroid hormone treatment.
C. Surgical resection of the abnormal thyroid.
D. Radioactive iodine treatment.
Answer: C
DISCUSSION: When a multinodular goiter enlarges enough to cause
symptoms of tracheal compression, surgical treatment is usually
required if the patient is considered a reasonable operative risk.
Medical treatment may be effective in preventing the initial growth of
the goiter but is unlikely to cause enough regression to relieve
symptoms. Radioactive iodine can occasionally be used to cause some
regression in patients who are poor anesthesia risks, but this is a
temporizing treatment rather than a definitive one.
2. The most precise diagnostic screening procedure for differentiating
benign thyroid nodules from malignant ones is:
A. Thyroid ultrasonography.
B. Thyroid scintiscan.
C. Fine-needle-aspiration biopsy (FNAB).
D. Thyroid hormone suppression.
Answer: C
DISCUSSION: Analysis of multiple series in which patients with thyroid
nodules have undergone FNAB has demonstrated a false-negative
rate of 2.4% and a false-positive rate of 3.3%. Sensitivity for this
method is 92%; specificity 74%. This surpasses the other methods for
accurate selection of patients who require surgical resection.
,3. The preferred operation for initial management of a thyroid nodule
that is considered suspicious for malignancy by FNAB is:
A. Excision.
B. Partial lobectomy.
C. Total lobectomy and isthmusectomy.
D. Total thyroidectomy.
Answer: C
DISCUSSION: There is a consensus that the initial minimum operation
for a nodule suspected to be malignant is total lobectomy and
isthmusectomy. Partial lobectomy or excision of the nodule is
associated with a higher risk of local recurrence if the nodule proves
to be malignant. Reoperation on the side of a partial lobectomy can
be technically difficult and associated with a higher risk of recurrent
nerve injury. Ordinarily, total thyroidectomy is not performed until a
conclusive diagnosis of malignancy is established.
4. Advantages of total thyroidectomy for management of papillary
carcinomas of the thyroid larger than 1.5 cm. include:
A. Possibility of using radioactive iodine postoperatively to identify
and treat metastases.
B. The ability to use thyroglobulin levels as a marker for recurrence.
C. Lower overall recurrence rate.
D. Lower risk of hypoparathyroidism.
Answer: ABC
DISCUSSION: Following total thyroidectomy iodine 131 can be used
more efficiently because of the absence of normal thyroid tissue,
which has greater affinity for iodine than papillary carcinoma tissue.
When all normal thyroid tissue is removed, serum thyroglobulin,
which is produced by normal and malignant thyroid tissue, becomes a
more effective marker for recurrence. The overall recurrence rate is
lower for patients undergoing total thyroidectomy, but the risk of
hypoparathyroidism is higher for patients who have total
thyroidectomy instead of unilateral lobectomy.
5. Which of the following statements about follicular carcinoma is/are
true?
A. It presents at a later age than papillary carcinoma.
B. It disseminates via hematogenous routes.
C. It is the most common type of well-differentiated thyroid
carcinoma.
D. Extensive angioinvasion portends a poor prognosis.
E. Follicular carcinomas are frequently multicentric.
Answer: ABD
,DISCUSSION: Follicular carcinoma is more common in older patients
(peak incidence in the fifth decade). The tumor has a marked
propensity for vascular invasion and spreads hematogenously to
bone, lung, liver, and central nervous system sites. Local nodal
metastases are less common than in papillary carcinoma. Extensive
angioinvasion indicates a less favorable prognosis. Papillary
carcinoma is the most common type of well-differentiated thyroid
carcinomas. Follicular carcinomas are rarely multicentric.
6. A familial form of medullary thyroid carcinoma (MTC) should be
suspected whenever:
A. The tumor is multifocal.
B. The tumor is bilateral (foci of tumor are present in both thyroid
lobes).
C. Pathologic examination of the resected thyroid gland reveals the
presence of C-cell hyperplasia in areas of the gland adjacent to foci of
MTC.
D. All of the above.
Answer: D
DISCUSSION: Sporadic MTC is unilateral in at least 80% of cases.
However, in patients with MTC occurring as a component of the
multiple endocrine neoplasia (MEN) type 2A or type 2B syndromes,
the tumor is virtually always multifocal and bilateral. Typically, in this
setting the MTC appears as multiple whitish-tan tumor nodules in the
middle and upper thirds of each thyroid lobe.
A diffuse premalignant proliferation of the C cells of the thyroid is
thought to precede the development of MTC in patients with familial
MTC. This proliferation, known as C-cell hyperplasia (CCH), consists of
parafollicular clusters of increased numbers of C cells. The finding of
CCH in areas of the thyroid adjacent to gross foci of MTC is strong
evidence for familial MTC.
7. All of the following are components of the MEN type 2B syndrome
except:
A. Multiple neuromas on the lips, tongue, and oral mucosa.
B. Hyperparathyroidism.
C. MTC.
D. Pheochromocytoma.
Answer: B
DISCUSSION: MTC and pheochromocytoma occur in both MEN 2A and
MEN 2B syndromes. Patients with MEN 2A may also develop
hyperplasia of the parathyroid glands. Although some investigators
, have reported equivocal histologic abnormalities in the parathyroid
glands of patients with MEN 2B, hyperparathyroidism is not a
component of this syndrome.
In contrast to patients with MEN 2A, those with MEN 2B have a
characteristic phenotype, including a tall, thin “marfanoid” habitus.
Patients with MEN 2B also develop multiple neuromas on the lips,
tongue, and oral mucosa, creating the appearance of thick lips.
8. MEN 2A and MEN 2B syndromes are associated with germline
mutations in:
A. The p53 tumor suppressor gene.
B. The H-ras gene.
C. The N-myc gene.
D. The RET proto-oncogene.
Answer: D
DISCUSSION: Germline mutations in the RET protooncogene, a
receptor tyrosine kinase that maps to chromosome 10, are associated
with MEN 2A and MEN 2B syndromes. Homozygous loss of the tumor
suppressor gene p53 is associated with the Li-Fraumeni syndrome,
and mutations of p53 are present in a variety of human neoplasms.
Point mutations in the H-ras gene are associated with carcinoma of
the colon, lung, and pancreas. Amplification of the N-myc gene, when
present in neuroblastoma, suggests a poorer prognosis.
9. Which of the following are true concerning islet cell neoplasms of
the pancreas in patients with MEN type 1?
A. Islet cell neoplasms in patients with MEN 1 are characteristically
multicentric.
B. The most common islet cell neoplasm in patients with MEN 1 is
gastrinoma.
C. Islet cell neoplasms in patients with MEN 1 may be malignant.
D. All of the above.
Answer: D
DISCUSSION: The pathologic change in the pancreas of patients with
MEN 1 is typically multicentric. Diffuse hyperplasia of islet cells and
microadenoma formation are often identified in areas of the gland
distant from grossly evident tumor. Tumors are commonly multifocal.
Islet cell neoplasms of the pancreas occur in 30% to 80% of patients
with MEN 1. The most common islet cell neoplasm in these patients is
gastrinoma. Gastrinomas associated with MEN 1 probably account for
20% to 50% of all cases of the Zollinger-Ellison syndrome. The second
most common islet cell tumor is insulinoma. Other pancreatic islet cell
neoplasms, such as glucagonoma, somatostatinoma, or vasoactive
Surgery Lecture Notes, Books, MCQ and Good Articles
Friday, September 5, 2008
Enocrine Surgery MCQ
1. When progressive enlargement of a multinodular goiter causes
symptomatic tracheal compression, the preferred management in
otherwise good-risk patients is:
A. Iodine treatment.
B. Thyroid hormone treatment.
C. Surgical resection of the abnormal thyroid.
D. Radioactive iodine treatment.
Answer: C
DISCUSSION: When a multinodular goiter enlarges enough to cause
symptoms of tracheal compression, surgical treatment is usually
required if the patient is considered a reasonable operative risk.
Medical treatment may be effective in preventing the initial growth of
the goiter but is unlikely to cause enough regression to relieve
symptoms. Radioactive iodine can occasionally be used to cause some
regression in patients who are poor anesthesia risks, but this is a
temporizing treatment rather than a definitive one.
2. The most precise diagnostic screening procedure for differentiating
benign thyroid nodules from malignant ones is:
A. Thyroid ultrasonography.
B. Thyroid scintiscan.
C. Fine-needle-aspiration biopsy (FNAB).
D. Thyroid hormone suppression.
Answer: C
DISCUSSION: Analysis of multiple series in which patients with thyroid
nodules have undergone FNAB has demonstrated a false-negative
rate of 2.4% and a false-positive rate of 3.3%. Sensitivity for this
method is 92%; specificity 74%. This surpasses the other methods for
accurate selection of patients who require surgical resection.
,3. The preferred operation for initial management of a thyroid nodule
that is considered suspicious for malignancy by FNAB is:
A. Excision.
B. Partial lobectomy.
C. Total lobectomy and isthmusectomy.
D. Total thyroidectomy.
Answer: C
DISCUSSION: There is a consensus that the initial minimum operation
for a nodule suspected to be malignant is total lobectomy and
isthmusectomy. Partial lobectomy or excision of the nodule is
associated with a higher risk of local recurrence if the nodule proves
to be malignant. Reoperation on the side of a partial lobectomy can
be technically difficult and associated with a higher risk of recurrent
nerve injury. Ordinarily, total thyroidectomy is not performed until a
conclusive diagnosis of malignancy is established.
4. Advantages of total thyroidectomy for management of papillary
carcinomas of the thyroid larger than 1.5 cm. include:
A. Possibility of using radioactive iodine postoperatively to identify
and treat metastases.
B. The ability to use thyroglobulin levels as a marker for recurrence.
C. Lower overall recurrence rate.
D. Lower risk of hypoparathyroidism.
Answer: ABC
DISCUSSION: Following total thyroidectomy iodine 131 can be used
more efficiently because of the absence of normal thyroid tissue,
which has greater affinity for iodine than papillary carcinoma tissue.
When all normal thyroid tissue is removed, serum thyroglobulin,
which is produced by normal and malignant thyroid tissue, becomes a
more effective marker for recurrence. The overall recurrence rate is
lower for patients undergoing total thyroidectomy, but the risk of
hypoparathyroidism is higher for patients who have total
thyroidectomy instead of unilateral lobectomy.
5. Which of the following statements about follicular carcinoma is/are
true?
A. It presents at a later age than papillary carcinoma.
B. It disseminates via hematogenous routes.
C. It is the most common type of well-differentiated thyroid
carcinoma.
D. Extensive angioinvasion portends a poor prognosis.
E. Follicular carcinomas are frequently multicentric.
Answer: ABD
,DISCUSSION: Follicular carcinoma is more common in older patients
(peak incidence in the fifth decade). The tumor has a marked
propensity for vascular invasion and spreads hematogenously to
bone, lung, liver, and central nervous system sites. Local nodal
metastases are less common than in papillary carcinoma. Extensive
angioinvasion indicates a less favorable prognosis. Papillary
carcinoma is the most common type of well-differentiated thyroid
carcinomas. Follicular carcinomas are rarely multicentric.
6. A familial form of medullary thyroid carcinoma (MTC) should be
suspected whenever:
A. The tumor is multifocal.
B. The tumor is bilateral (foci of tumor are present in both thyroid
lobes).
C. Pathologic examination of the resected thyroid gland reveals the
presence of C-cell hyperplasia in areas of the gland adjacent to foci of
MTC.
D. All of the above.
Answer: D
DISCUSSION: Sporadic MTC is unilateral in at least 80% of cases.
However, in patients with MTC occurring as a component of the
multiple endocrine neoplasia (MEN) type 2A or type 2B syndromes,
the tumor is virtually always multifocal and bilateral. Typically, in this
setting the MTC appears as multiple whitish-tan tumor nodules in the
middle and upper thirds of each thyroid lobe.
A diffuse premalignant proliferation of the C cells of the thyroid is
thought to precede the development of MTC in patients with familial
MTC. This proliferation, known as C-cell hyperplasia (CCH), consists of
parafollicular clusters of increased numbers of C cells. The finding of
CCH in areas of the thyroid adjacent to gross foci of MTC is strong
evidence for familial MTC.
7. All of the following are components of the MEN type 2B syndrome
except:
A. Multiple neuromas on the lips, tongue, and oral mucosa.
B. Hyperparathyroidism.
C. MTC.
D. Pheochromocytoma.
Answer: B
DISCUSSION: MTC and pheochromocytoma occur in both MEN 2A and
MEN 2B syndromes. Patients with MEN 2A may also develop
hyperplasia of the parathyroid glands. Although some investigators
, have reported equivocal histologic abnormalities in the parathyroid
glands of patients with MEN 2B, hyperparathyroidism is not a
component of this syndrome.
In contrast to patients with MEN 2A, those with MEN 2B have a
characteristic phenotype, including a tall, thin “marfanoid” habitus.
Patients with MEN 2B also develop multiple neuromas on the lips,
tongue, and oral mucosa, creating the appearance of thick lips.
8. MEN 2A and MEN 2B syndromes are associated with germline
mutations in:
A. The p53 tumor suppressor gene.
B. The H-ras gene.
C. The N-myc gene.
D. The RET proto-oncogene.
Answer: D
DISCUSSION: Germline mutations in the RET protooncogene, a
receptor tyrosine kinase that maps to chromosome 10, are associated
with MEN 2A and MEN 2B syndromes. Homozygous loss of the tumor
suppressor gene p53 is associated with the Li-Fraumeni syndrome,
and mutations of p53 are present in a variety of human neoplasms.
Point mutations in the H-ras gene are associated with carcinoma of
the colon, lung, and pancreas. Amplification of the N-myc gene, when
present in neuroblastoma, suggests a poorer prognosis.
9. Which of the following are true concerning islet cell neoplasms of
the pancreas in patients with MEN type 1?
A. Islet cell neoplasms in patients with MEN 1 are characteristically
multicentric.
B. The most common islet cell neoplasm in patients with MEN 1 is
gastrinoma.
C. Islet cell neoplasms in patients with MEN 1 may be malignant.
D. All of the above.
Answer: D
DISCUSSION: The pathologic change in the pancreas of patients with
MEN 1 is typically multicentric. Diffuse hyperplasia of islet cells and
microadenoma formation are often identified in areas of the gland
distant from grossly evident tumor. Tumors are commonly multifocal.
Islet cell neoplasms of the pancreas occur in 30% to 80% of patients
with MEN 1. The most common islet cell neoplasm in these patients is
gastrinoma. Gastrinomas associated with MEN 1 probably account for
20% to 50% of all cases of the Zollinger-Ellison syndrome. The second
most common islet cell tumor is insulinoma. Other pancreatic islet cell
neoplasms, such as glucagonoma, somatostatinoma, or vasoactive
